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The political ambiguity is, mostly, resolved. Very shortly, appointments will be made to Clinical Commissioning Groups (CCGs). At the same time appointments will be made to the local arm of the NHS Commissioning Board (now to be known as the “Area”), the NHS Commissioning Board Sectors (formally known as SHA Clusters), and Commissioning Support services. What was theoretical is becoming something very tangible.

Over a year ago we ran a simulation to try and understand how the proposed reforms might work. It is fascinating to be sensing many of the issues playing out for real. What is even more fascinating is sensing a new dynamic emerging that may, given half a chance, prove to be a really positive change.

One of our CCGs has been forged by the merger of three early Pathfinder groups. This was a consequence of a development event we ran last year with the seven CCGs being proposed at that time. They explored their ability to discharge both the governance of a statutory body and commissioning functions, within the management budget they have been allocated. At the end of the event, before they went home, three CCGs agreed to start discussing a merger. Experiential learning can be a powerful development tool!

The merger means the CCG has three really strong localities. The GP leads from these localities are determined to build on the work done over the last two years and the focus they have on improving quality and use of resources for their patients. They recognise that there are things they need to collaborate on, not only as localities but also with the other CCGs in Lincolnshire. That collaboration will be important to manage the issues that PCTs have previously had to grapple with, but what came across really forcefully was the professional desire to seize the opportunity to really make changes at a local level that would improve care for their patients in a way, probably, that PCTs couldn’t. Sitting alongside them was a manager tasked with establishing commissioning support services (CSS) for the CCGs. Buying the functions they need, at scale, from the CSS makes sense—they will hold the CSS to account, in collaboration with other CCGs, whilst leaving space and time for them to work on culture, transformation, and quality within their localities—tackling issues which matter to professionals and patients.

This new, emerging, dynamic could mean things will be different. What will really matter is the attitude and approach the NHS Commissioning Board Area team bring. Will they treat the CCGs as if they are simply replacements for PCTs and have the same expectations and demands of CCGs that PCTs have experienced? That interface will be critically important to whether these reforms mean more of the same, or the creation of a new dynamic in commissioning for the NHS. Time will tell.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.

You don’t mention Health and Wellbeing Boards: are these not involved at all in the processes you describe?

Martin Mcshane

Thanks. It is a good point. This is only one particular dynamic and, as you rightly point out, the interaction with the Health and Well Being Board is another important new dynamic in the system. The CCGs are well engaged, locally, with the Health and Well Being Board. Other colleagues participate but I don’t and so feel constrained from making observations.

Richard Smith

I find it very gratifying to read your blogs, Martin, and get some sense of what’s happening on the ground in the NHS rather than in the overheated political stratosphere. I had the chance to meet informally with a CCG recently, and they described the strong pressure they had experienced from the “centre” to do things in a particular way. They were determined to resist and do what they thought best for their community, but they also thought that many CCGs would succumb. What do you think?